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Rise of the machine: Robotic prostate surgery as part of the treatment paradigm
Marc Laniado MD FEBU FRCS(Urol)
UKGDV04170006ah;Nov2017
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Disclosures
• No paid consultancy
• No industry grants
• Conflicts of interest:
§ Share ownership in Nuada Medical - a company that provides MRI-targeted transperineal prostate biopsies equipment
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Prostate cancer: a big problem
Black: 1 in 4 diagnosed, 1 in 12 die
Asian: 1 in 20 diagnosed, 1 in 44 die
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White: 1 in 8 diagnosed; 1 in 24 die
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PCa should respond to early treatment if cancer spreads sequentially
Localised Prostate Secondary spread to boneLymph nodes involved
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If so, screening should reduce numbers with metastases
Localised Prostate Secondary spread to boneLymph nodes involved
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↓ Metastatic prostate cancer after PSA testing late 1980s, unlike breast
cancer
Welch 2015 NEJM
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Screening using PSA & transrectal ultrasound prostate biopsies led to 21% less deaths
Organised PSA screening compared to NONE ⬇ 21% chance of dying, 50% fewer mets at presentation
ScreenedUncreened
Schroder 2012 NEJM
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After diagnosis, disease-risk, life expectancy & patient preferences
determine management
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Life expectancy determines need for curative treatment:< 10 y: conservative/palliative treatment> 10 y: curative treatment
Age and life expectancy
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Higher disease stage requires treatment, even in older men with short life expectancy
Localised Locally advanced
Images from Prostate Cancer UK
Advanced
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Patient preferences & trade-offs important in deciding treatment
Avoid dying Hoping for long life May need to accept these
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Treatment for clinically localised cancer dependent on disease risk & tumour location
Radical prostatectomy
Active surveillance
Low Risk PCa
favourable, Intermediate-Risk PCa
High Risk PCa
Radical RadiotherapyBrachytherapy Focal
Therapy
unfavourable, Intermediate-Risk PCaD
isea
se R
isk
Trea
tmen
t
Adapted from NCCN/AUA/ASTRO 2017
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Androgen deprivation therapy, chemotherapy & radiotherapy for advanced prostate cancer
Androgen deprivation therapy androgen antagonists Chemotherapy
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Multiple treatments may be needed over time
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mpMRI gives anatomical location of cancer & widens treatment options
Cancer
Targeted biopsy:Gleason score 4 + 3 = 7Maximum cancer core length8 mm
Classified as“unfavourable, intermediate risk prostate cancer”
Age 71 yearsNo comorbidityPSA 8 mcg/L
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For unilateral, intermediate-risk PCa, focal therapy treats cancer, keeps erections & continence
Prostate cancer on one side only
Half the prostate treated ∴ fewer side-effects
CAVEAT: Focal therapy regarded as ‘experimental’ & not ‘standard of care’ or ‘usual care’ because no long-term comparative data with existing treatments
HIFU treatment animation
Valerio 2014 Eur UrolFeijoo 2016 Eur Urol
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mpMRI essential post-focal therapy to identify treatment success/failure
UnaffectedNeurovascular
bundleAblated cancer
Nerve bundle
Follow up with MRI over time Dickinson 2017 Urol Oncol
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MRI identifies men for nerve-sparing surgery but more accurate by intraoperative check of prostate margin - NeuroSAFE technique
NERVE BUNDLE
• Cancer close to nerve bundle
• Nerve bundle preservation:- Benefit: better erections & continence
- Risk: leaving cancer at surgical margin & cancer recurrence
• NeuroSAFE: intentional nerve spare, prostate sent for frozen section, if tumour at margins —> secondary removal of nerve bundle
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mpMRI: tumour contact length identifies wider margin needed & predicts PSA rise after surgery
Long tumour contact length indicates surgical technique modification: more tissue to be removed Kongnyuy 2016 Urol Onc
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mpMRI can identify SV invasion
Surgical technique needs to be modified to preserve tissue around seminal vesiclesBrachytherapy unsuitable
Radiotherapy needs to include the SVUnsuitable for low-dose rate brachytherapy
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mpMRI improves surgical selection: avoid men with short sphincter, ⬆ incontinence
Mungovan 2016
Short membranous urethral length (MUL) associated with incontinence – need 13 mm
Matsushita 2015
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Robotic prostatectomy traditionally releases bladder from abdominal wall
Weakens continence support
Hernias more common
Easy to remove fat from front of prostate
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New ‘Retzius-sparing’ approach to prostatectomy gives fastest continence recovery
Posterior approach preserves bladder & urethral attachments important for continence
Fewer hernias compared withanterior approach
Impossible by open surgery
Demonstrated at RCTDalela 2017 Eur Urol
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Anterior tumours indicate either traditional anterior approach or modification of Retzius-sparing
technique
Tumour
Traditionally, fat not removedPotentially ⇧ positive margins
Adapted approach: Incision includes going far anterior to take fat
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Controversy over benefit of robotic vs open prostatectomy
But all studies analysed were BEFORE Retzius-sparing V anterior approach RCT
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Summary mpMRI & robotic prostatectomy
• Selection of men more suitable for active surveillance
• Selection of men for focal therapy
• Avoidance of men with short sphincters & risk for incontinence
• Plan extent of “radical” and/or nerve sparing surgery
• Modification or adaption of surgical approach to robotic prostatectomy